Beliefs and common sense guide us in making myriad decisions every day. However, because we believe something to be true or judge it to be true based on "common sense", doesn't make it true. A belief can be validated only by testing it with evidence. This blog is neither right nor left, but undoubtedly will annoy individuals across the spectrum who hold unsupported convictions. My hope is that this blog will encourage us to challenge each others' beliefs and, most importantly, our own.

Sunday, April 24, 2011

Rally Around the Peanut?

Last month in Edgewater Public Elementary School in Volusia County, Florida, a group of parents picketed the school protesting measures that had been taken to protect an 8 year old student with severe peanut allergies. Measures being taken included banning lunches from the classroom and requiring children to wash their hands and rinse their mouths prior to entering the classroom.

On April 20, CNN reported that the US Department of Transportation, after requesting public comment on possible measures to protect passengers with peanut allergies, declined to take any action, stating: "The Department is prohibited by law from restricting the serving of peanuts aboard aircraft unless a peer-reviewed study determines that serving of peanuts causes severe reactions among airline passengers. There has been no such peer-reviewed study, so we declined to take action at this time."

Peanut allergies are not at all uncommon and vary greatly in terms of how large a dose of peanut allergens is required to trigger a reaction and the severity of that reaction. There is debate about how many individuals are actually subject to very severe peanut allergic reactions. However, there are certainly people for whom even airborne exposure to peanut allergens can cause a severe allergic reaction and even death.

Assuming that the child involved in the Florida case does indeed have such a severe allergy, does the inconvenience of the measures imposed by the school really outweigh the safety of the child? In order to avoid inconveniencing other children, should this child be forced to withdraw from public school? The presence of the affected child should be used as an opportunity to teach the other children in the school that in our society we are considerate of the needs of others, particularly when those needs involve protecting life. What example did the protesting parents think they were providing for their own children?

Parenthetically, in this particular case, the “inconvenience” of hand-washing is really a boon. Many infectious diseases are transmitted by dirty hands – and judging from the frequency of hand-washing I observe in public restrooms, we have a dirty-hand epidemic in this county. In my opinion, hand-washing instruction should be part of every elementary school curriculum (it is currently also taught to medical and nursing students).

Regarding the serving of peanuts on airplanes, I wonder whether the legislation preventing the Department of Transportation from imposing restrictions on this practice was inserted at the behest of the peanut lobby. The twelve year old legislation required that a peer-reviewed study be completed before the agency impose any regulations. Apparently, the legislation did not include measures to ensure that such a study would actually be conducted.

I am a very strong proponent of conducting prospective experimental studies to guide policy decisions. However, for a passenger with a very severe peanut allergy, one does not need a new study to determine that he/she would be put at risk by other passengers munching on peanuts in the close confines of an airplane cabin. In any case, one is not going to put such an individual at risk in the context of a study. So if such an individual requests a peanut-free flight it certainly would seem reasonable to have the airline comply without requiring any new study.

In order to determine whether all flights should be made peanut-free, one could conduct a study documenting the number and severity of reported peanut allergic reactions that occur during peanut-serving airplane flights. Presumably, individuals with very severe allergies already do not fly on airlines that serve peanuts and thus would not be included in such a survey. Thus regardless of the outcome of such a study, it would seem appropriate that airlines make flights peanut-free upon request of a very sensitive individual.

Peanuts are my favorite airplane snack. However, I would be more than happy to give them up until I reached my destination in order to allow a fellow human being to safely share the same flight.

There are many situations where it is not justified to burden the majority for the benefit of a small minority. However, when the inconvenience to the majority is de minimis and the benefit is the prevention of a truly life-threatening situation for an individual, we should happily bear a peanut-size burden. It is a sign of civilization.

4 comments:

We must however also consider the possibility that by restricting the exposure of children to infectious agents, we are encouraging their immune systems to attack whatever is at hand. See for instance the case of the man who intentionally contracted hookworm to (successfully) cure his allergies. Instead of hand-washing, the immune systems of the young may well benefit from more playing in the dirt.

Dudley, thank you for sharing your comment. There has been a long term increase in the reported incidence of allergies in developed countries. Many hypotheses have been advanced to explain this observation including the “hygiene” hypothesis that you alluded to which postulates that exposure to micro-organisms and parasites during childhood is protective and that our environment is now “too clean.” On the other hand, another hypothesis is that the increase results from modern environmental factors such as exposure to indoor air pollution in modern tight buildings built and furnished with artificial materials which emit chemicals. I don’t think that any of this is settled science.

What we do know with great confidence, however, is that hand-washing reduces the spread of infectious diseases including those affecting the gastrointestinal system, the respiratory system, and the skin.

The hookworm therapy story is an interesting one, which to my knowledge, has yet to be clinically validated in prospective randomized clinical trials. Hookworm therapy has also been proposed for treatment of inflammatory bowel disease (also to my knowledge not clinically validated). One speculative mechanism in the latter case is that the bacteria in the hookworm’s excrement rebalances the bacterial flora in the patient’s gut.

By definition, an allergy is a reaction to a normally harmless substance. If you carefully insulate someone from that substance, they will develop allergies to other substances. This is because allergies are the result of an attempt by the immune system to compensate for a lack of stimulation (i.e. illness). You're SUPPOSED be sick most of the time. Really. Allergies are the result of not being routinely ill.

Hand-washing is exactly the wrong thing to do. Kids aren't getting dirty and sick enough, that's why they have allergies. There is an increasing body of study that bears this out.

There is no support for the "chemical poisoning" hypothesis which makes no sense at all. Why would chemical exposure lead someone to have a peanut allergy? Until a substance is identifies that directly causes the immune system to "misfire" (i.e. you're exposed to compound x and you suddenly develop allergies to random substances in your environment) this hypothesis seems dubious.

Truly lethal food allergy attacks are extremely rare (less than 20 per year), and I would argue are probably unavoidable.